Nonaccidental Trauma in Pediatric Elbow Fractures: When You Should Be Worried

Abstract

Background: Nonaccidental trauma (NAT) is a rising source of morbidity and mortality in the pediatric population. Fractures are often the first cause for presentation to health care providers in the case of NAT but can be misidentified as accidental. Given that elbow fractures are the most common accidental injuries among pediatric patients, they are not traditionally associated with NAT. This study aims to determine the prevalence of NAT among elbow fractures and identify common features in nonaccidental elbow fractures. Methods: Current Procedural Terminology (CPT) codes were used to retrospectively identify all pediatric (0 to 17) elbow fractures at a single, tertiary children’s hospital between 2007 and 2017. Among these, all fractures for which an institutional child abuse evaluation team was consulted were identified. The medical record was then used to determine which of these fractures were due to NAT. Standard injury radiographs of all victims of NAT as well as all patients under 1 year of age were blinded and radiographically evaluated for fracture type by a pediatric orthopaedic surgeon. Results: The prevalence of nonaccidental elbow fractures across the 10-year study period was 0.4% (N=18). However, the prevalence of nonaccidental elbow fractures in those patients below 1 year of age was markedly higher at 30.3% (10/33). Among all elbow fractures in patients below 1 year of age, supracondylar humerus fractures were the most common fracture type (19/33, 57.6%), yet transphyseal fractures (6/33, 18.1%) were most commonly the result of NAT (5/6, 83.3%). In children over 1 year of age, fracture type was not an indicator of NAT. Conclusions: The vast majority of pediatric elbow fractures (99.6%) are accidental. However, certain factors, namely age below 1 year and transphyseal fractures increase the likelihood that these fractures may be a result of NAT. Level of Evidence: Level IV: retrospective case series.

Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review

“…Nonetheless, there exist distinctive fracture characteristics that more commonly align with NAT, thereby warranting heightened vigilance from medical providers. Age is the most significant predictive factor for identifying a non-accidental source [29,57,58]. In a study by Worlock et al, approximately 10% of fractures in children under 18 months are due to abuse, compared to 0.5% of fractures in children between 19 and 60 months [57].…”

What’s New in Pediatric Orthopaedics

“…Tadepalli et al reviewed 4,415 elbow fractures and found that the rate of nonaccidental trauma in patients <1 year of age was 30% 4 . Another series quantified the risk that a fracture is due to nonaccidental trauma to be 13 times greater for a transphyseal fracture than for a supracondylar humeral fracture 5 .…”